Basic Information
| Provider Information | |||||||||
| NPI: | 1801416359 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRANSFORMATIVE PHYSICAL THERAPY & WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 RIVER DR S APT 203 | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073103701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122273233 | ||||||||
| FaxNumber: | 8665495687 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 AVENUE C | ||||||||
| Address2: | |||||||||
| City: | BAYONNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070023012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122273233 | ||||||||
| FaxNumber: | 8665495687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2020 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | THAKKAR | ||||||||
| AuthorizedOfficialFirstName: | SUNNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2122273233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 40QA01588700 | 01 | NJ | STATE LICENSE | OTHER |